Patient Registration Form

Page {{ paginatorProps.current }} of {{ paginatorProps.total }} ({{ paginatorProps.percentage }}% completed)
Personal Details

Information we need to register you with the practice
Please note all fields marked with a * are mandatory for your registration

 
Processing
Previous UK GP Registration
 
Processing
Current Details
 
Processing
Previous Address & Surgery Details

Please help us to trace your medical records by providing details of where you previously lived and which GP practice you were registered with

 
Processing
Next Of Kin Details

By completing this section, you are giving your consent for us to contact your Next of Kin in the event of an emergency or accident

 
Processing
Medical Information
 
Processing
Additional Information
 
Processing
Lifestyle Information
 
Processing
Patient Signature

I declare that the information I give on this form is correct and complete.

 
Processing
Patient Declaration for all patients who are not ordinarily resident in the UK

Anybody in England can register with a GP practice and receive free medical care from that practice.

However, if you are not ‘ordinarily resident’ in the UK you may have to pay for NHS treatment outside of the GP practice. Being ordinarily resident broadly means living lawfully in the UK on a properly settled basis for the time being. In most cases, nationals of countries outside the European Economic Area must also have the status of ‘indefinite leave to remain’ in the UK.

Some services, such as diagnostic tests of suspected infectious diseases and any treatment of those diseases are free of charge to all people, while some groups who are not ordinarily resident here are exempt from all treatment charges.

You may be asked to provide proof of entitlement in order to receive free NHS treatment outside of the GP practice, otherwise you may be charged for your treatment. Even if you have to pay for a service, you will always be provided with any immediately necessary or urgent treatment, regardless of advance payment.

The information you give on this form will be used to assist in identifying your chargeable status, and may be shared, including with NHS secondary care organisations (e.g. hospitals) and NHS Digital, for the purposes of validation, invoicing and cost recovery. You may be contacted on behalf of the NHS to confirm any details you have provided.

A parent or guardian should complete this section on behalf of a child under 16 years of age

 
Processing
Signature
 
Processing
NON-UK EUROPEAN HEALTH INSURANCE CARD (EHIC), Provisional Replacement Certificate (PRC) Details and S1 Form

Complete this section if you live in another EEA country, or have moved to the UK to study or retire, or if you live in the UK but work in another EEA member state. Do not complete this section if you have an EHIC issued by the UK.

If you are visiting from another EEA country and do not hold a current EHIC (or Provisional Replacement Certificate (PRC))/S1, you may be billed for the cost of any treatment received outside of the GP practice, including at a hospital.

By using your EHIC or PRC for NHS treatment costs your EHIC or PRC data and GP appointment data will be shared with NHS secondary care (hospitals) and NHS Digital solely for the purposes of cost recovery. Your clinical data will not be shared in the cost recovery process.

Your EHIC, PRC or S1 information will be shared with The Department for Work and Pensions for the purpose of recovering your NHS costs from your home country.

European Health Insurance Card

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

 
Processing

Page you are trying to access does not exist.